New Leaf Counseling Services, LLC Prescreen Questionnaire
Sign in to Google to save your progress. Learn more
First and Last Name *
Contact number: *
Email: *
What interests you about joining our private practice? *
Which work location(s) are you interested: *
Required
What type of work are you seeking? *
Ideally, how many patients do you desire to see weekly? *
What hours would you be scheduling patient appointments? A minimum of two evenings preferred. *
What days of the week would you be scheduling patient appointments?
 *
Required
Which population age groups are you comfortable counseling? (Check all that apply. ) *
Required
What diagnoses do you have experience and comfort counseling?  (Ex: Trauma, Anxiety, Depression, ADHD, ASD, ODD, SUD, etc...) *
What frameworks or interventions are you most comfortable using in your sessions? *
What are your strengths as a clinician? *
Have you made mandated reports? *
What license(s) do you currently hold active? *
Has your license always been in good standing? *
Are you requesting supervision for advancement in licensure for the state board? If so, please describe supervision and clinical work hour requirements still needed. *
What measures do you take to support your own mental health? *
Date available to start as an Independent Contractor with New Leaf Counseling Services, LLC? *
Additional comments you would like to add:
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of nlcsteam.com. Report Abuse
Google Forms